Tuesday, September 23, 2008

My Magnificent Octopus

“ Black Adder: “What have you got there Baldrick?” Baldrick, “I have written a story. My Magnificent Octopus.” Blackadder: “I think you mean Magnum Opus”.

Baseline Study

We are in our last month in Uganda and will shortly be returning to the US. The end of an era, we will have done six years in East Africa. It has been an experience I would not have missed for the world. I have been back at school for all this time.

My final task has been to undertake a Baseline Study on Malaria, AIDS and TB grouped under the latest aid acronym (MAT) in Luwero and Kiboga Districts, in Central Uganda, for a major NGO. In many ways the results summarize what I have discovered about health and healthcare in this part of the world over the past years and I think it might be worthwhile sharing them.

Just to give some context, the two districts are archetypal Uganda, rural, heavily agricultural, poor infrastructure and communications and little disposable income. There are almost three-quarters of a million people living in the area. The burden of disease, particularly malaria, HIV/AIDS and TB is very high, malaria overwhelms the healthcare system the whole year round.

The Study was designed in three parts: first a detailed survey of every health facility in both Districts, from hospital down to Health Facility Level II - the clinics that serve Parishes, which contain a number of villages - about 75 health facilities in all. Second, a household Knowledge, Attitude and Practice (KAP) sampling survey covering about 100 households in each District, rural and urban, total population over 200 households comprising about 1500 people. Third, a detailed examination of the information systems.

It was great fun and hugely educational. I visited and talked with healthcare workers and the people they serve, many miles from the nearest town or paved road. I saw up close the results of the millions of dollars of aid that the USA and other countries pour into development in Uganda and other African countries annually

A Perfect Storm

In summary, the study identified a ‘perfect storm’ resulting from the concatenation of number of events: a rapidly increasing population ( the Total Fertility Rate is 6.9) with a concurrent huge increase in the incidence of infectious disease, particularly malaria; rising expectations amongst the population, resulting from increased awareness and education; Uganda’s healthcare workforce crisis, there are severe shortages of trained healthcare workers at every level; de-centralization of healthcare, which has spread healthcare resources even more thinly, and chronic under-resourcing and neglect of the national healthcare system. The result is two Districts whose healthcare systems are in crisis. My experience suggests that they are indicative of the rest of the country.

In order to give my story a little more life than a turgid Study Report, I have decided to use the format of a [very lengthy] email I wrote to a long-suffering friend, describing my findings and thoughts on the issues. It may not follow the rules of grammar but I hope it makes the subject less dense


Malaria

Everyone [we interviewed] knows what causes it and where ‘mozzies’ live and breed. Everyone knows who is at greatest danger, moms and babies. Everyone knows how best to protect themselves and families, Insecticide Treated Nets (ITNs)
Yet less than 40% of the population has an ITN in their houses, very few have two. If you read the newspapers and the advertising of the UN and big NGOs, you would imagine the entire country draped in the ‘things’. Despite the imploring of Bob Geldorf and the rest, the promise of ‘nets for all’ is a myth, we found one facility with a dozen
nets available for hand out in over 75 facilities we surveyed. Almost all [ITNs] are bought and at large cost to families with little disposable income.

Healthcare workers complain constantly about advising moms at ante-natal clinics (ANC) to use a net and yet don't have any to hand out. It is really bad for morale.
Uganda needs to flood the market with free nets to the point where they have no retail value, and there are enough spare to decorate wedding venues and to use for fishing nets, both common practices here

About 60% of all patients visiting health facilities at every level, are diagnosed with malaria. 97% are diagnosed symptomatically. About 60% are diagnosed by nursing or health assistants, with very little training or experience. About 30% are diagnosed by volunteer Village Health Team (VHT) or Community Medicine Distributors (CMDs)
workers, with a couple of weeks training on an array of diseases. About 90% of suspected malaria patients are treated with Artemisinin Combination Therapy (ACT). The drug is handed out by formal health workers and volunteers, like M&Ms.

ACT has rapidly become the most sought- after drug in the Ministry of Health (MOH)
inventory. MOH offer it free of charge. It has become a source of alternative income for many healthcare workers who either sell it to their patients or to businessmen who shift it to DRC and Sudan. The result is an erratic and unreliable supply of ACT. Patients worried about availability, take the drug for 2 of the 3 days prescribed
and then horde the rest, for the next attack on them or their children. It does not take a PhD to know what constant and widespread subclinical exposure of any drug does to its efficacy I think we are on a fast track to ACT resistance, which I believe will be quicker and more terrible than the Chloroquine/Fansidar debacle

60% welcomed Internal Residual Spraying with DDT, 20% opposed the
idea, 20% didn't care. IRS has started in the North, Apac and Oyam Districts, with very good results It has now been stopped thanks to a court injunction lead by British American Tobacco (BAT(U)) and Dunavant Cotton Int. They worry that DDT will leach from the homes and contaminate their crops. The idea of organic tobacco beggars my imagination and vocabulary.

The strategy of providing intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) to pregnant women, though great in theory ( it offers considerable protection to pregnant mums when they are their most vulnerable) is hugely flawed. Most women only come to a health center once during pregnancy,
so they only get IPT1, they need the second dose, IPT2, for better protection, few get the latter. Only 30% of Ugandan women deliver in a health facility.

My general comment about Uganda's Roll Back Malaria plan is it might more aptly be named Operation Sisyphus.



HIV/AIDS

Everyone knows how it [HIV] is spread, 'sex and needles'. Everyone knows how to prevent infection, condoms, faithfulness and abstinence, in that order of import
Knowledge appears to impact little upon behavior. Condoms are available free, even in the most remote locations. Few men use them consistently. Fertility rates in both Districts are estimated at 7. Multiple sexual partnerships, particularly males fathering children with more than one woman, are commonplace.

Prevention of Mother To Child Transmission (PMTCT) is less well known about and the practice very poorly organized. Only 10% of interviewees knew the details. Again, the problem is that PMTCT relies upon regular ANC attendance and subsequent delivery in a health facility. I cannot see the current 30/70% balance changing in the near future. The healthcare system could not cope

Everyone knows about Anti Retro-Virals (ARVs). Everyone knows about HIV testing. Many women test, usually at ANC but often too at outreach clinics now known as HIV Testing and Counseling (HCT): note the change from ‘Voluntary’. Few men test. It seems they don't want to face the truth. HIV testing remains difficult to find in rural areas. HIV testing is scary for all and still carries much stigma. There is a distinct lack of national leadership in testing. The Tanzanian model, the President and First Lady testing in public, is one that. should be copied here. My conversation with the local Anglican bishop, that he might lead a local public HIV testing ‘fair’, fell on stony ground.

ARVs are limited in distribution and erratic in supply. The nearest supply point for a rural villager is Health Center III, at the sub-county level a two day round-trip for many people. Long gaps in ARV treatment are commonplace. HIV treatment in general, is threatened by inept and corrupt national management of medicines and medical equipment by the National Medical Stores (NMS). The term 'Stocks Out' ( medicines have run out) has been incorporated into the national languages. The number of new cases of HIV is increasing faster than the number being put on ARVs
Current methods of prevention appear to be having little impact. There is a dearth of new ideas in prevention


Tuberculosis (TB)

Pulmonary TB is reaching epidemic proportions in both districts. An alarmingly small number know how TB is spread. If you don't know how a disease is spread how can you protect yourself? Few make the connection between HIV and TB. Many TB patients are HIV +. The data is too erratic and poor to give an accurate picture of the % of TB/HIV. Almost 50% of TB patients we found in our survey remained positive at the end of treatment with first-line drugs and had to begin second-line treatment. Directly Observed Treatment Strategy (DOTS) therapy is taken seriously but is undermined by the erratic supply of drugs from MOH. I have had a cough since half-way through the survey

Health Facilities and Staff

Morale in the healthcare system is at an all-time low. MOH is viewed as incompetent and corrupt, by staff and patients. Government is viewed as uncaring and mean-minded with regard to funding healthcare. Salaries and conditions of service for all healthcare workers are so poor as to encourage corruption and neglect.
Kiboga District hospital can fill only 28 out of 88 established nursing posts. Most Level II facilities have about 25% of staff, about two healthcare workers. The quality and experience of staff is as much a concern as the numbers. Many posts are filled by individuals who lack the required qualifications, training and experience. The result is a high level of [symptomatic] diagnosis and treatment, well above the level of staff competency. Less than twenty of the sixty five healthcare units surveyed have working laboratories, it is little wonder that symptomatic diagnosis is the norm.

Housing and accommodation for staff is as big a problem as pay, it stymies recruiting and undermines morale. Continuing professional education is jealously guarded as the prerogative of the most senior staff. Many healthcare workers run private clinics and shops selling medicines, resourcing them with misappropriated medical supplies.
Without this option they would merely subsist.

Very few facilities have any form of power supply and most close at night Few have running water, the staff carry it in jerry cans from the nearest well. Disposal of medical waste is totally ad hoc and quite frankly dangerous. The only hospital in Kiboga hospital has not had running water in 21/2years and has no incinerator either. The daily bonfires are nauseatingly smelly.

The NMS has a contract with a private company to remove out of date medicines. it has never visited the hospital. Out of date medicines are stacked outside next to the hospital kitchen. There is not one functioning ambulance in the entire Kiboga District.
The total annual drug budget for Kiboga is UGSH 200m. Given a population of 280,000, this allows UGSH 770 (50c) ppa.

Some Suggestions

Given the extent of the problems I have detailed in the report, it would be of little value for me to leave it all hanging in the air. As a soldier, I was taught to argue to a decision rather. than simply a conclusion. So I have a few suggestions to offer.

I think we should enhance malaria diagnosis at HC II level through a Malaria Rapid Test and increase community-based oversight of malaria treatment with ACT through a DOTS approach. I think we could increase IPT2 provision by delivery through CMDs and VHTs and increase the availability of ITNS by the same method. There is an urgent need to initiate regional Preventive Education programs for PMTCT and also for TB. There is a vital and urgent need to refurbish clinical laboratories if we are to have any hope of improving diagnosis and treatment.

Finally, and again to quote Baldrick, “I have a cunning plan” to increase the number of men who test for HIV. It involves Corporate Social Responsibility and the 2010 Football World Cup. I will resist the temptation to elaborate further and save the details for my future essay

The Culture of Co-Dependence

Well! That is my "Magnificent Octopus" . Six years in Africa has convinced me the only way we will break the 'Culture of Co-dependence' we call Aid but should properly call Charity, is to find some new ideas. We must centre our thinking around business development and job creation. The dignity of a job is vital for the future stability of Africa's ever-growing and youthful population.

I frequently upset my fellow travelers with what I offer as new ideas, and they consider to be unfair sniping at the Aid Industry. I am currently proposing a six-month moratorium on workshops and conferences. I am informed it would do untold damage to the hotel and catering industries as well as Coca Cola and numerous
Chinese tee shirt and baseball cap manufacturers.

I have also developed an irrational antipathy to certain aid industry jargon; its use has the same effect on me as dragging fingernails down a blackboard. To name a few: sensitization, holistic, gender-based, participatory and most irritating of all ….. youth-friendly! A more patronizing expression is difficult to imagine, it suggests that the young are incapable of understanding the same information as adults, whereas the truth in my experience, is the opposite. Perhaps it is time to take a break.

Saturday, May 24, 2008

More Frantz Fanon Than Xenophobia

I watch with sadness, but no great surprise, the horrors being played out in the townships of South Africa: they were inevitable. Overnight, the arcane term xenophobia has become part of African discourse, describing seemingly incomprehensible, irrational violent acts by a section of South African society.

The extent of African leaders’ cognitive dissonance over this issue is exemplified by the Kenyan Foreign Minister Moses Wetangula in a recent comment, "[A]long its bumpy road to independence, South Africans were scattered all over the continent, including Kenya. "We gave them tremendous and admirable hospitality (...) The last country anybody would imagine would engage in xenophobia is South Africa."

The Minister has lost the plot. This tragedy is not a manifestation of racial or ethnic hatred. It is about economics in its crudest form. Outsiders, legal or illegal, Zimbabwean or Ugandan are hated because they are competing, often successfully, with poor South Africans for jobs and wealth. Despite the rosy picture of South Africa as the economic engine of the Continent, social and economic inequality is institutional. The gap between rich and poor is a chasm, at its deepest in the townships around the big cities, where the majority of the population are young, poor and uneducated. The nation has an unemployment rate about 40%, much higher in the townships and the majority are young men. South Africa has an unenviable reputation for violent crime, mostly perpetrated by the poor on the poor

Over the past decade, despite expansive promises from the government, little has been done to improve the lot of the urban poor. Their seething anger has finally exploded into awful violence against the nearest and most vulnerable, poor immigrants.

It is ironic that a Kenyan political leader would announce, he was perplexed by South Africa’s crisis. His inability to draw parallels with recent events in Kenya is depressing. The trouble in South Africa has similar echoes. I was not surprised then either.

The Kenyan crisis was a long time coming, but the factors have been in place many years; ever-increasing population pressure with over 80% of the population squeezed onto less than 10% of the land. Kenya has a very young population (average age, 18 years) and an economy unable to keep pace with population growth, rapid urbanization and the ever rising expectations of the poor urban young. There is a yawning chasm between the rich and the poor, a leadership shamelessly misappropriating the nation's resource and endemic corruption at every level of society.

The result is a vast number of young men without jobs in Kenya. I contend the most dangerous creature on Earth is a young man without a job. This is as true of Newcastle, New Orleans and Najaf as it is Nairobi. Young men without jobs view themselves as outside of society, disenfranchised and owing nothing to their communities.

Not only do they [young Kenyans] not have a job; there is little hope of the majority finding one. Moreover, and here there are clear echoes in South Africa, though tourism is a vital part of the economy it also enables poor Kenyans who come in contact with relatively affluent tourists, to see 'how the other half live' and to contrast their own lives and prospects.

These angry young men are fertile ground for the seeds of anarchy. The portent to the recent storm had long been obvious in the high levels of violent crime endemic to the country, not for nothing is Nairobi known as 'Nairobbery’ and comparisons made with Johannesburg. The rise of the secret and violent Kikuyu sect Mungiki, and its mirror organization, the Kalenjin Warriors, were also harbingers of terror to come.
Even through the narrow prism of the TV camera, it was clear that the majority of those committing violence were young men; their common denominators, anger, frustration and poverty. They had nothing; so having nothing to lose, focused on destroying all and everything. The gangs on camera in Kisumu looked and behaved exactly like the ones in Gauteng.

For those who still cannot see the writing on the wall, I suggest Frantz Fanon's, The Wretched of the Earth. What we see in Gauteng today and Kibera months ago, he describes as 'catharsis through violence’.

Those who prefer their logic on a bumper-sticker will continue to cluck and prattle about tribalism and xenophobia. What we are witness to in Africa today, is much more; the concatenation of three irresistible social forces: the unequal distribution of wealth, population pressure and the revolution in rising expectations.

The ‘have-nots’, particularly the urban poor, can see how little they have, measured at first hand against the urban ‘haves’. They want a share. If anyone wants to know what comes next, try A Tale of Two Cities by Charles Dickens.

So what of the future? The violence in South Africa will simmer down much as it has in Kenya. The young unemployed, will return to violent crime, mostly robbing the poor, occasionally the rich, and the anger will slowly build up until it explodes, more violently, in the future.

Spinoza offered, "There is no hope without fear and no fear without hope". Maybe the fear created by this current bout violence will galvanize South Africans and Kenyans into radical change. It will take much moral courage and huge effort. In practical terms, there must be a more equitable distribution of the nations’ wealth, mainly through the creation of jobs, lots and lots of them.

A word to the wise; Uganda must draw lessons from both these crises. I see the same dark clouds on the horizon. Corruption is endemic, the gap between the rich and the poor, huge. The population is growing at a frightening rate and the nation's leadership is in an advanced state of denial on this issue. It is even younger than Kenya’s at less than 15 years. As optimistic as I am about Uganda and its wonderful people, it is plain to see that current economic growth is an order of magnitude behind the population boom and the people’s ever rising expectations.

Moreover, the young are rapidly rejecting traditional lives as agriculturalists and urbanization is almost as rapid as population growth. Not because there is no land to work, but because the young envision more than what they see as life in a hut, with a paraffin lamp and hoeing a row of maize, far from friends and the Premier League on GTV. Yet many who migrate to the towns and cities fail to make a living. The ever-rising crime rates across the nation and the recent terrible spate of violent crime in Kampala are testament to the growing anger and frustration of the urban poor

Prediction is no more than entertainment, but without radical new thinking and bold action, I am gloomy about the future of South Africa, Kenya and indeed Uganda. I offer only this from a man much cleverer than I.
“A world of this magnitude of inequality is inherently unstable. Peace is in the palm of the devil” - Fouad Ajami

Tuesday, May 13, 2008

Now For Something Completely Different

“Insanity: doing the same thing over and over again and expecting different results.” 
Albert Einstein

Back in 2005, I wrote a piece for a US healthcare magazine with the hugely pretentious title, ‘Of Hamlet and Per Diem’, I am now embarrased about the name, but article itself attracted considerable email flak, which was fun, It began as a discussion of Uganda’s long battle against HIV/AIDS and went on to describe how the focus had been lost, through a mixture of corruption, ideology and above all, a lack of original thinking, particularly in the hugely lucrative arena of HIV/AIDS Prevention. As a finale, I offered what I considered to be an original idea. Here it is in its in edited form:

“If, as I have argued, Uganda’s HIV/AIDS strategy is dysfunctional, what is to be done? Well, we cannot continue doing what we have always done and when it shows not to be working, try harder and throw more money at it. The time has come for original thinking and novel approaches. The key must be to reduce the opportunities for misappropriation, get more of every dollar donated, to land on the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.”

“Here is my ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan Bank. I will then advertise for 1,000 volunteers from the next intake of Freshers at Makerere University. All will be required to undergo an HIV test. The first 1,000 ‘negatives’ will have a bank account opened in their name, a ‘health savings account’, containing $900.”

The contract will be they remain negative until they graduate. Immediately before graduation, they will be tested again and those still negative will have unrestricted access to their savings account, to do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m from the Global Fund I could impact on 200,000 people). This may seem a lot of money for a relatively small number of people, but in my time in Africa I have seen much more spent for much less impact.”

“I can hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’ etc. I offer the following for consideration:
Many more than 1,000 will volunteer; the ‘Positives’ will be able to seek treatment and long-term care, the ‘Negatives’ will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years
Money spent on administration will be minimal (much less than most current prevention programs).
Opportunities for misappropriation and mismanagement of funds will be negligible
On successful graduation, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money will probably be spent in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status.
Individuals will recognize that they are capable of determining their own future.”

“I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. That might be true, but is it any more odious than many current schemes? At least it has no moral or ideological strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?”

Now why have I reprised this piece of public health apostasy “bordering on the immoral” (as one critic described it) at this time?
Well it seems that not everyone thinks it’s nonsense, the World Bank appears to have at least one person who inhabits the same parallel universe as me. This report by the Financial Times in late April 2008 outlines a program that aims to provide a financial incentive to encourage people in Tanzania to ‘avoid unsafe sex’:

[T]housands of people in Africa will be paid to avoid unsafe sex, under a groundbreaking World Bank- backed experiment aimed at halting the spread of Aids. The $1.8m trial – to be launched this year – will counsel 3,000 men and women aged 15-30 in southern
rural Tanzania over three years, paying them on condition that periodic laboratory test results prove they have not contracted sexually transmitted infections.
The proposed payments of $45 equate to a quarter of annual income for some participants. The programme, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, marks an important step in the fight to tackle Aids, which claims 2m lives a year.
In spite of billions of dollars spent annually on treatment and prevention worldwide, there were about 2.5m new HIV infections in 2007, predominantly in Africa. Carol Medlin from the University of California, San Francisco, one of the researchers, said: “We hope
this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short- term behaviour.”
The Tanzanian experiment is a big advance in efforts to test public health ideas more rigorously, with some participants placed in a control arm not offered payment in order to track the effects of the
programme precisely.
“Conditional cash transfers” have already been used in Latin America to motivate poor parents to attend health clinics, and have their children vaccinated and schooled. The designers of the Tanzanian programme believe that payments of $45 when combined with careful counselling could play an important role in reducing HIV infection, especially for vulnerable young women.

The study will be conducted by the Ifakara Health Research and Development Centre in Tanzania, in conjunction with researchers from the University of California, Berkeley, the University of California, San Francisco and the World Bank. The Tanzanian trial programme, which is still subject to fine-tuning and ethical approval, will not specifically test for HIV, which is costly and already widely conducted in the country. It will use proxies , including gonorrhoea, and guarantees any participant found to be infected receives state treatment.
By Andrew Jack in London
Published: April 25 2008
The Financial Times Limited 2008

Whilst I am not yet saying, “I told you so!” I am encouraged that the HIV/AIDS industry might at last , after 20 years and countless billions of dollars, be trying to find alternatives to wornout and anemic ‘prevention’ activities encapsulated in meaningless jargon like, ‘sensitization’, ‘community mobilization’, ‘user-friendly youth services’ and ‘behavioral change’. Prevention strategies that are rarely if ever rigorously evaluated and yet judging by the numbers ( 2.5 m new cases in 2007) appear to be as effective as African road-signs.

In researching this article I came across one of the key architects of this concept of ‘conditional cash transfers, a chap with the splendid name of Meade Over., a Senior Fellow at the Center for Global Development, where he works on issues related to the economics of efficient, effective and cost-effective health interventions in developing countries. And his work is very impressive. His thinking is refreshingly original. Anyone who has an interest in HIV/AIDS would do well to visit his blogsite at: http://blogs.cgdev.org/globalhealth/2008/04/pay_for_prevention_a_1.php

I recommend not only the short article on ‘Pay for Prevention’ but also his working paper on the failure of Prevention and its future impact on the President’s Emergency Plan for AIDS Relief (PEPFAR)

After six years in East Africa peering closely at a disease that has killed millions, brought out the best and the worst in people and made many of the latter wealthy, I know I am at risk of incurable cynicsm. This glimmer of new thinking gives me fresh hope. I am still looking for a donor!

Sunday, April 27, 2008

World Malaria Day

This past week has seen World Malaria Day, aimed at focusing the world's resources on irradicating this ancient and terrible disease. On Sunday I caught and article in the Washington Post, 'Eradicating Malaria Worldwide Seen As a Distant Goal at Best'
The article, well written and compelling, stirred me to write down my thoughts on the subject.

I live in a place that has the highest number of infected mosquitoes in the world, a District in northern Uganda. That's what the Ministry of Health and WHO tell me. It also has the third highest fertility rate, 1.2m babies born each year. Average age of population 14.9yrs. Put the two together and you get a huge infection rate that without radical action will continue to grow with the population explosion. Most deaths from malaria are babies, kids under five and pregnant women. It is not just deaths either, my town has a huge number of disabled children, their brains damaged by being boiled by malaria fevers or by being directly infected by the parasite

There is no silver bullet solution. My current work, a baseline study on malaria/HIV/TB gives me a close up view of the reality of malaria. The people tell me they cannot live 24/7 under an ITN, they often get bitten in the evening, eating supper or doing homework. They tell me too I should try sleeping under a net in a 12' hut crammed full of people on a red hot airless night. I can imagine. I have a big net in a 12' bedroom and a fan on all night. When the electricity fails (often) I sweat buckets and find it hard to sleep. I understand why, despite the risks, the people don't use them every night.

Moreover, most people here view malaria the way people in the US or Europe view a bad cold, and sometimes thats how it affects fit, healthy adults with partial immunity. So data on the disease is hugely inaccurate. There are already reports of ACT resistance, though no confirmed data. . I am not surprised, ACT like other antimalarials, is frequently used without firm clinical diagnosis. If the symptoms disappear after ACT treatment, it must have been malaria. ACT is costly; the stuff, now given free by MOH, it is often stolen, repacked and ends up for sale in village shops and even in neighboring countries. Health centers in my District, which have no ACT, direct patients to buy from the 'chemist shops', often supplied by the same healthcare workers. Selling medicines is often justified as the only means of subsidizing very poor salaries.

The nation's healthcare system is overwhelmed by population pressure and the burden of disease and under-mined by shameless corruption. The brain drain of healthcare workers, migrating to the US, Europe and other developed countries, to escape the appalling conditions of work and pitiful salaries, is accelerating the dissolution of the national health service.
There is no history of any nation with a ruined healthcare system ever successfully conquering any infectious disease, least of all one as old and complex as malaria

IRS, using DDT, the cheapest, most effective agent, has just begun here. It remains to be seen whether the expansion of the malaria campaign into a coherent, focused effort to include IRS, ITNs, ACT and education will have lasting impact on the disease, but I am pessimistic, without a vaccine.

As expected the campaign to use IRS is being dogged by the pious ranting of the self-appointed guardians of Africa's ecosystem, as if Africans were too stupid to understand the arguments and reach their own decisions. I have little time for such organizations as Beyond Pesticides. One would do well to remember that its staff earn a comfortable living through this NGO, lobbying on behalf of poor Africans. They have very comfortable offices, alongside the the lobbyists of E Street in DC. Their office rent would buy a huge number of ITNs.

They know the scientific evidence they quote is based upon massive use of DDT as a pesticide in US agriculture in the 1960s, when planes were used to dump tons of DDT per acre on cotton fields and fruit orchards. Even with this massive industrial overuse, the evidence, after 50 years of scientific scrutiny, connecting DDT with diseases in humans is thin indeed. IRS will use less DDT in a year across the entire country, than was dumped on a few acres of US cotton in the 60s

My advice to anyone who wants a credible voice at the table, is to come and live here, out in the countryside, away from the Cities, for a couple of years. To live without expensive Malarone prophylactics and designer insect repellants and about 200 miles from the nearest capable hospital

They are welcome to come with me to the villages to convince people they need to use an ITN all the time. They could also try and explain their version of the facts regarding IRS and DDT; tell mothers that "DDT can be passed on in breast milk". For many it will be an irrelevance, they will not be feeding their dead babies.
4/27/2008 7:15:09 AM

Saturday, April 26, 2008

The Global Health Workforce Crisis

‘Over several decades, a global health-workforce crisis has developed before our eyes. The crisis is characterized by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers,
and poor working conditions.’
- World Health Organization. World health report 2006

There Were Reports
In late February I was surprised to find our home-town, Lira in northern Uganda, in the international news. And it wasn’t a 60 word paragraph by Reuters. Lira made it all the way to the hallowed ground of the Lancet Editorial; fame indeed! Actually one might better describe it as infamy.
Now I for one know the temptation of purple prose, but I expected more of the Lancet. Given our remoteness from London, or for that matter, anywhere on Earth, I can only surmise the Editor got his information from the Ugandan ‘Dailies’, which delight in hyperbole. The result was an opening paragraph that read:

“Earlier this month, medical workers at Lira Hospital in northern Uganda went on strike to demand unpaid allowances promised by the government for working in this war-torn area. Seven patients died. There were reports of bodies decomposing in wards and women in the maternity ward assisting with each other’s deliveries. “

Let’s set the record straight. I was there when it happened. The lady that keeps our house went into labor; I took her to the hospital, witnessed the chaos and took her to a private clinic. I wrote a blog about it called ‘Super Tuesday’. I followed events very closely for the next few days.

The healthcare workers went on strike because they had exhausted every other option. They had been promised the money for almost a year, every other healthcare worker in the Region had received an ‘allowance’ and they had been stone-walled. This is not uncommon. Teachers commonly go for months without being paid their tiny salaries of about $100 a month. It usually happens because some bureaucrat has ‘eaten the money’, a local euphemism for stolen it.

The brave but na├»ve District Medical Officer of Health, was publicly derided when he suggested that the ‘seven patients who died’ would have died with or without healthcare workers present. Knowing the resources available to the hospital, I do not doubt him. ‘Women assisting each other with their deliveries’ is another hyperbole. Most Ugandan women come to deliver in hospital with droves of mothers, aunts and sisters; some with their own village birth attendant. That’s how the deliveries were done. As for, ‘bodies decomposing in wards’; this a hot place, there are no undertakers. Funerals take place pretty quickly.

Global Forum
The irony of this strike is that it took place a few weeks before the first WHO Global Forum on Human Resources for Health, hosted in Kampala. That, I suppose is why Lira made the Editorial, coincidence. I did not attend the Forum; no report has yet been published. I have however, received anecdotes aplenty. Given the scale and political complexity of the [healthcare workforce] crisis, it is not surprising that the meeting produced a lot of heat but little light.

Exploitation
What happened in Lira was a reflection of events played out every day across Africa, which has 25% of the world’s disease burden and only 3% of the world’s health workers. The reasons as to why this imbalance exists are manifold, but the political heat centers around one argument, the migration of healthcare workers, trained in Africa, at African expense. The accusation is they are lured away by unscrupulous recruiters with promises of huge salaries, to meet the ever-rising demands of caring for the aging population of the developed world, leaving their own countries bereft and in crisis.

In the eyes of many, this is yet another example of predatory exploitation of African resources by the developed world. In condemnation, the Lancet editorial ends with a pious flourish, “[R]icher countries can no longer be allowed to exploit and plunder the future of-resource poor nations” . Such sanctimony suggests migrating doctors and nurses are victims of a modern slave trade. Nothing could be further from the truth. Many leave because it is in their nature to explore and seek advancement; but for the majority it is because working in healthcare at home is under-paid and overwhelming. Moreover, despite the promises of the international community and the proclamations of African governments, in most countries, there are no signs of things improving, rather they are getting worse.

Distortion
Responsibility for the distortion in the healthcare workforce can as easily be laid at the feet of the huge numbers of Non Government Organizations and International Agencies as it can ‘malign foreign recruiting agencies’. It is they (INGOs) who recruit the cream of the public sector, offering in-country salaries and employment opportunities that cannot be matched by governments. It is the dream of many of my medical friends to get permanent employment with ‘a big international NGO’ or better still the ‘Holy Grail” of international healthcare employment, the WHO.

The extent of this distortion is evinced by the number of surgeons and surgical staff in Africa. Uganda for example, has about 75 general surgeons and ten physician anesthetists for a population of 30 million people. Most live and work in Kampala. The majority of surgery is performed in rural hospitals by the equivalent of family physicians. Why this dearth of surgical capability? In part because the public sector pays poorly, private surgery is limited and few INGOs are into surgery, so rarely hire surgeons. Better by far to enter a career in public health and specialize in HIV, TB and Malaria, that’s where the [NGO] money is. To emphasize the point, Makerere University recently restricted entry into its Masters in Public Health program to physicians.

The reasons for Africa’s healthcare worker crisis are too many and complex for reasoned debate in this essay. They will no doubt be the subject of many future PhD theses. I will offer a few comments about two factors, using Uganda as an example; few countries on the continent are markedly different.

Overburdened
The first is that of population pressure. Uganda is undergoing a population explosion. The national Total Fertility Rate - about 7 - is the third highest in the world. As a result, despite the ravages of war, disease and staggeringly high maternal and infant mortality rates, the population has leapt from 6m in 1962 to about 27m in 2007. Moreover, average life expectancy has dropped, mainly due to HIV/AIDS, producing a skewed population with a mean average of 14.9 years. Barring some apocalyptic event, Uganda’s population will reach 60m by 2025. Economic growth is nowhere near keeping up with this massive and rapid population increase; every aspect of national infrastructure is overburdened. Electrical power is rationed, schools are overwhelmed with pupils and have pitiful resources, roads are falling to pieces as fast as they are built and emergency services non-existent in most of the country. Uganda has for example, ten fire trucks; four are in Kampala. Nowhere is this overburdening more obvious than in healthcare.

I offer a few anecdotes in illustration; first in the arena of mother and child care. I am currently working on a project in Luwero District, central Uganda. Recently I visited the largest healthcare unit in the District, called a Level Four health center; there is no Referral Hospital, though there are about a million people in the District. The unit is small, old and in disrepair. The maternity unit has ten beds and one delivery room with one table. When I looked in, there were 15 women who had delivered in the past 12 hours, five were on the floor. The overworked but dedicated midwife told me they averaged 450 deliveries a month. She added that other smaller District health centers were similarly overstretched. This is in an area where about 60% of women deliver at home.

My next-door neighbor is the only surgeon in Lira hospital. He was away during the strike, but some weeks before he had experienced an incident that exemplified the sheer weight of his work and the paucity of resources. Late one evening a truck loaded with worshippers returning from a ‘Revival’, overturned about ten miles from town. The town has no emergency services; the casualties arrived in traditional fashion, in the back of private vehicles, usually pickup trucks co-opted by the police as ‘Good Samaritans’. By the end of the night he had 90 casualties; seven had died instantly or en route. His only assistants were a family doctor doing Ob/Gyn, an Anesthetics Officer and a handful of nurses. Help, in the form of one doctor arrived the following day. It took him three days and nights to complete the surgical care for his 90 patients.

A few weeks ago, in a town not far from here, a furor erupted over the town mortuary. Plans to refurbish the unit had run out of money. However, the doors at least were fixed. This, according to the town council was major improvement. Prior to that, dogs had chewed of parts of bodies and local ‘thugs’ had used the place to skin stolen goats and cows that would end up in public butchers. The council stated that hygiene remained a problem however. “The mortuary has neither a refrigerator nor is connected to electricity and given there are no drugs for preservation of bodies, some end up rotting”.

As I was preparing to write this article I glanced at a short byline in a national daily. I offer it verbatim. “Close to 200 health centres across the country can no longer offer immunisation services after they ran out of gas for the refrigerators in which the vaccines are preserved. In a] survey done in 22 districts by a concerned party within the Ministry of Health, out of 534 health centers sampled, 198 had stopped offering the services by the beginning of March. There has been no delivery of gas to the centres since January
15. Vaccine shortage poses grave risks to pregnant mothers and their babies who risk missing the tetanus immunity at the time of delivery. Uganda has at least 1.2 million children born every year countrywide”.

Corrupt and Inept
The second issue is that of Corruption and Ineptitude, so inextricably linked I consider them as one. Corruption has permeated every facet of public healthcare in Uganda, from the very top to the remotest health center. The reasons range from shameless greed at the top to survival at the bottom. But at root the problem is OPM (Other Peoples Money, a euphemism for foreign aid). Ugandan healthcare attracts huge amounts, too much for an inept bureaucracy to manage. The temptation to ‘eat it’ or miss-use it are huge, the results glaringly obvious. Headquarters MOH in Kampala has so many SUVs in its parking lots it has earned the sobriquet ‘Ministry of Land Cruisers’. Few of these vehicles ever leave Kampala city limits.

The previous Minister of Health and his immediate staff, currently face charges of misappropriating millions of dollars of Global Fund monies. Funds meant to buy and distribute anti-retroviral drugs, drugs for TB and antimalarials. A glance at the inquiry findings shows it was done with breath-taking impunity. My favorite anecdote concerned evidence given to the initial inquiry. The judge was shown a receipt for fuel for an MOH vehicle traveling thousands of kilometers around the country on “HIV sensitization duties”. The vehicle registration on the receipt belonged to a Caterpillar tractor. My friends were not amused; they called it ‘stealing from the dying’.

The upper-mid level of the Ministry has followed their leader’s example and the new Minister is not strong enough to break their stranglehold. The National Medical Stores (NMS) an autonomous governmental organization is so riddled with theft and ineptitude it has become a national scandal. The current Minister has publicly stated he wants the boss sacked, as yet to no avail. The NMS is the only means of supply and distribution of medicines and medical equipment to the public healthcare system. Its reputation for incompetence is all-pervading. The project I am currently working on has a caveat in the proposal regarding the availability of medicines and medical materials for HIV/AIDS, TB and Malaria, one line reads, “[N]MS itself has systemic problems that lead to stocks out”. That is a huge understatement.

Lira District health centers currently have no AARVs and have not had for months. Neither do they have the new antimalarial, Artemesin Combined Therapy (ACT) but I know at least four ‘chemist shops’ in town where I can buy them and just about anything else. Where and how they got them, the traders will not say. The same would probably be true in most of the country.
At the bottom of the food chain, a District Medical Officer of Health has just been charged with stealing a refrigerator and gas bottle from one of his health centers. It was found in his quarters, filled with beer. There is no word of the vaccines.

Ineptitude is not the sole prerogative of the MOH. Some of its INGO partners appear to have either given up their Sisyphean task or in some cases let the rock roll downhill. You will remember the anecdote about the maternity wing in Luwero. Directly across compound from this building there stands a brand new construction, built by one of the most renowned INGOs. Locked and never opened, it was built as a ‘center for acutely-malnourished children’. A laudable purpose, but acutely-malnourished children seem to be in short supply locally. The building would make a great new maternity unit.

About 10 miles out of town, down a very long muddy track, with a few small villages, there is a brand-new maternity unit, built by the same INGO. It dwarfs the Level Three healthcare center it serves, has about 50 beds and all the equipment required outside of emergency surgery. The problem is nobody uses it. Well; about 5 women a month have given birth in it since it opened, which is probably a good thing because it does not have one toilet, bath or shower. The midwives have dug a latrine outside. I just cannot figure out how it came to be built there, but there is a huge new house a little further down the track.

In conclusion, I admit to only touching the margins of the crisis Africa faces in healthcare and its healthcare workers but I hope I have provided some light and thought for debate. I will add one more comment. I consider the idea that doctors, nurses and other health workers born and trained in Africa should be prevented from working abroad to be abject sanctimonious nonsense. Why stop at healthcare workers? Why not ICT workers? University professors?

We should ask young doctors and nurses why they leave this beautiful, tropical country, their families and cultures, for the cold rain of Manchester, England or the frigid plains of North Dakota.
When we have listened to the answer, we will be some way to fixing the problem.

Monday, March 24, 2008

Bloody Hands and Bleeding Hearts

“[h]umanitarian agencies don’t mind coordinating with the military but they don’t like being coordinated by the military” ….Hugo Slim
Medical Diplomacy
It is almost a year ago today that I rather foolishly volunteered, without a second thought, to join a Project HOPE mission as the leader of a contingent of medical volunteers aboard the USNS COMFORT. The plan was for the hospital ship to visit twelve countries in Latin America and the Caribbean. Project HOPE would provide a group of about twenty five volunteers at any one time.
During this Odyssey, I wrote a couple or articles. In one I described the mission as an exercise in what had become known as ‘Medical Diplomacy’ and promised I would examine the issue in depth at a later date. The key issues, it seemed to me, centered around the relationship between NGOs, in this case Project HOPE, and the US military and the US Navy in particular. Is this a good model for future humanitarian operations? What does the US Navy get from it? What do NGOs like Project HOPE get from it? Is this a flag waving exercise or does it provide long-term good for the recipient countries and their people? I have procrastinated for almost four months since the end of the COMFORT mission; herewith my observations.
Nothing New
My first contention is that what Project HOPE did on the COMFORT was neither new nor innovative. They and a number of other NGOs had deployed on the USNS MERCY the previous year, on a similar mission in SE Asia. Whilst the COMFORT was sailing noisily around the Panama Canal, the USS Peleleu, with a contingent of HOPE volunteers, was quietly reprising the MERCY mission in SE Asia. Currently, a group of HOPE volunteers is aboard a USN ‘grey-hull’ off the coast of West Africa and the USNS MERCY prepares to sail, with HOPE volunteers and other NGOs for SE Asia in June.
Moreover, whilst relationships between the military and civilian humanitarians have certainly intensified over the last two decades, they are by no means new. As Hugo Slim notes in a series of excellent articles The Stretcher and the Drum: Civil—Military Relations in Peace Support Operations. The ICRC was born in 1863 out of the Battle of Solferino, the Save the Children Fund (SCF) in 1919 out of the First World War, and OXFAM and the US Committee for Aid and Relief Everywhere (CARE) out of the Second World War in 1942 and 1945 respectively. He points out that, to a large degree, “Militarism and humanitarianism have represented two sides of the same coin – humankind’s inability to manage conflict peacefully”.

The Birth of CIMIC
Perhaps the defining moment in recent NGO/military relationships was Operation PROVIDE COMFORT in northern Iraq in 1991. I think even the most hardened critics of civil/military cooperation (CIMIC) would agree that a great deal of good was done and many lessons learned. It’s a shame they were not remembered in the frequent man-made and natural disasters of the following decade; Bosnia, Rwanda, Kosovo to name but three, saw the CIMIC relationship as exercises in re-inventing the wheel. To misquote Santayana, ‘History repeats itself. It has to because nobody listens.”
More recently, conflict in Afghanistan, Iraq, the Tsunami and the Pakistan Earthquake have seen ever-increasing cooperation between INGOs (UN etc), NGOs and the military. With each experience the relationship has improved and the results too. But it has been a fraught and imperfect gestation.
New Tools
My second contention is that like it or not, the CIMIC approach to disasters either man-made or natural; is the model of the future, particularly and most contentiously with the aftermath of conflict known as Peace Support Operations Why? Because there is a growing revolution in thinking amongst the militaries of the world, that questions the utility of force. It argues that most modern conflict is so complex; militaries have only a limited role in their resolution, creating the conditions for a political solution. In other words creating and enforcing a secure environment.
The problem is, to butcher a quote from Maslow, ‘If the only tool you have in your toolbox is a hammer, all the world’s problems are nails’. The argument goes that the military needs new tools, new methods, new training to meet the demands of modern conflict. Like Colossus it moves and changes slowly, but the change is inexorable. We can already seeing US Army Artillery Regiments putting away their field guns and learning about peace support, civil affairs and COIN. But the military has so much to learn and little time to learn it in. Moreover, there are skills and expertise it finds difficult to obtain and impossible to retain; skills essential to Disaster Relief and Peace Support Operations. For example how many veterinary officers does the Navy have? It must therefore form alliances with the UN and with NGOs of every shape and size, local and international, to provide this expertise in order to achieve what it calls, ‘winning the battle for hearts and minds’..
So the first point I would make about Medical Diplomacy, I have in part, made before; it is an experiment, an honest attempt to explore ideas old and new to meet demands that appear to be inescapable. The people of America and indeed the world, want conflicts, where they are inevitable, to be resolved in ways other than bombing cities until the rubble bounces. This will require the military and civilian humanitarian agencies to work in very close concert from the outset. This in turn will require them to think, plan and train together.
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Pre-Planned Humanitarian Missions
You might ask why this discussion has focused so far, on disasters and conflict, when the organization at the center of my argument, Project HOPE, has historically not been involved with the military post-conflict, in what are fashionably called Peace Support Operations. In fact it has only been involved with the military on one recent Disaster Relief operation, the Tsunami. All of HOPE’s other sojourns with the military were and are to date, archetypal preplanned ‘cold’ Humanitarian Assistance operations.
So I must return to the original questions. Why would HOPE want to be involved in these sorts of missions? What does it get from them? What does it contribute? How does it justify such a close working relationship with the military?
Pragmatism
The answer to the first question is pragmatic and banal. HOPE used to have its own ship. In fact it started using it 50 years ago this year, beginning in SE Asia and then moving along the Pacific coast of Central and South America. It got too old and expensive; HOPE let it go and became land-lubbers with long-term capacity building programs. There are many such HOPE programs around the world, some conventional healthcare and development programs; others very out of the ordinary. HOPE is currently completing the building and staffing of a Children’s Hospital in Basrah, Iraq. It has even taken on the training of nurses and other clinical staff, in what I consider to be a model method; the subject of a future article.
Project HOPE has always had a hankering to return to its seaborne roots and the US Navy has provided the means and much more. They provide what an NGO needs to survive and work in a hostile environment, security, logistics and communications. Much the same as the military provides NGOs in CIMIC operations the world over.
Given the essential political/military nature of these missions, NGOs like HOPE don’t get much of a voice at the table when it comes to deciding where to go or for how long to stay. But that need not be a deterrent to joining. With planning and forethought, NGOs with long-term interests in a specific geographic area can capitalize on the Navy’s presence. Operation SMILE used the COMFORT mission in Latin America to obtain logistic support, communications and clinical resources for surgery and post operative care in a number of countries. The US Navy shared in the kudos of this unique service and a number of Navy medical staff both learned and taught local healthcare workers.
Project HOPE used the journey for similar purposes; to conform to military argot, I called it ‘armed reconnaissance’. We deployed teams of healthcare Volunteers who undertook an array of clinical and teaching roles in concert with their Navy counterparts. At the same time we used this work to create relationships with the MOHs, local NGOs and civil society and to identify new long-term capacity building training and education projects for HOPE. We have potential new projects in Panama and a number of other Latin American countries at this time.
The preplanned, ‘cold’ Humanitarian Affairs mission of the COMFORT/MERCY type, also provides a medium for the thousands of volunteers from all over the US and beyond, who want contribute their time and there expertise but only have a little of the first. Many are willing to give a few weeks of their time to provide what HOPE is looking for, expert teaching and training of healthcare skills in under-served regions of the world. The HOPE/US Navy partnership provides a relatively uncomplicated means for these individuals to serve. Vitally, in an era of the All-Volunteer Military, it also offers a chance for civilians to experience and perhaps understand a little of military life.
Experience as Value-Added
The case for HOPE’s contribution to this aspect of CIMIC is a little more complex and I need to tread carefully for fear of sounding like the archetypal arrogant NGO. Military medicine in general and Navy medicine in particular have much to learn about Humanitarian Assistance and Disaster Relief. The average Navy doctor, nurse and medic is a very busy person working in a peacetime facility. Their customers are fit health young men and women with mainly fit healthy families, who leave before they get old and sick. Moreover, many of the navy medics are young and inexperienced and have been trained according to rigid protocols with state of the art, resources. When they are suddenly thrust into an environment where every affliction known to man is common-place, resources are minimal and people ‘wing’ the protocols, it is a chastening experience and a tight learning curve.
It is in this environment that the HOPE volunteers provide the value-added. Most are experienced in working in austere environments; HOPE deliberately seeks and selects those with previous NGO, volunteer, missionary experience. The Volunteers become the teachers and trainers, often at the behest of the Navy medics. It is this role, of education, training and expertise that HOPE promotes as its contribution to these missions. Whether the ‘student’ is an indigenous, doctor, nurse, community midwife, or a US Navy corpsman or nurse, really is not the issue. It is about capacity building through education and training. That is HOPE’s contribution
Continuity Factor
There is another aspect, the continuity factor. When the COMFORT sailed on her 12 country mission last year, she had a complement of about 850 souls, from the Navy, AF, Army, USHPS, Coast Guard, Canadian Defense Forces and NGO volunteers. Most had never previously met and many had never been to sea before. It is not hard to imagine what the first few weeks were like. If we had been called upon to deal with a DR mission before week 4, I think we would have had real problems. The first month was a training exercise for all on board.
By the time the COMFORT sails on a future mission, almost everyone who sailed last year will be dispersed to the four winds, The CO and the leadership will be starting almost from scratch. The Mercy when she leaves for SE Asia in June will have exactly the same issues. These are the facts of life in the modern US Navy. Here again there is a role for NGOs who have access to experienced people who have ‘been there and got the tee shirt’.
Underpinning CIMIC
Finally, I want to try and bridge the gap between preplanned ‘cold Humanitarian Assistance missions and Peace Support Operations or whatever term the jargoneers in the five-cornered building are using this week.
Every, mission involving UN/NGOs/military (US and Coalition) I have served in or analyzed has labored at the beginning. It’s to be expected, it is the fog of war. But there are some deeper intrinsic reasons for this initial dysfunctional relationship. They might best be examined under the general rubric of communications. This is not a reference to ITC or radio communications, though they are always a bone of contention. The key is how to forge a working relationship, CIMIC, rapidly and efficiently, in a time of great stress. How to weld together a number of organizations often multi-national and multi-cultural in nature and with deeply differing views as to how to achieve a successful outcome.
Creating Understanding and Trust
The key principals of humanitarian agencies are impartiality and independence, luxuries rarely afforded the military – Bob Leitch
From 1991 in northern Iraq through to today in Helmand Province, the secret of a successful CIMIC operation has been how well the players worked as a team. The military generally knows what it has to do, the Commander’s Intent. How they get there is always a dynamic process, depending on the changing political environment and the actions of those who would thwart them. INGOs and NGOs too, normally have a pretty clear idea of what they intend to do and although they aim at impartiality, neutrality and independence their very presence shapes day to day events and the endgame. To achieve a common goal, the end of conflict, suffering and a return to normalcy, all parties have to know each other, know what that endgame is and how each team member intends to contribute. They have to know each others strengths and weaknesses, cultures and customs. Above all they have to trust each other, more often than not with their lives.
If, through projects such as the routine HA missions of the MERCY,COMFORT and ‘grey-hulls’, and focused interagency training courses, like the Army’s at Ft Polk, we could begin this process of understanding and building trust, this might shorten the time and ease the difficulties in establishing future CIMIC structures. We might, in turn, go into the next crisis better prepared and more rapidly produce a favorable outcome
This is my most defensible justification for ‘Health Diplomacy’ missions; in the manner Project HOPE and other NGOs are conducting them with the military, particularly the Navy. Both are developing and encouraging an ever closer relationship. The aim: to build a bridge, intellectual, institutional and above all cultural, between two organizations which as Hugo Slim says ‘represent two sides of the same coin.

Sunday, February 10, 2008

Super Tuesday

It is Super Tuesday here
and Sue and I have been glued to the SatTV. since early morning
At 1pm almost on the dot, there is a knock on the door.
It is Evelyn. She is the lady that looks after the house, cleans, dusts and does all the washing except our underwear, culture forbids.
Evelyn is a really nice young woman. She is 23 years old and has two girls, both at school, aged 6 and 7 years.
Her husband is a nice chap too. He has no formal education, no land, no skills and has recently finished DOTS for TB. So she looks after him too
Evelyn is the sole wage earner and is great at her job so gets spoilt. She now has a bike and a mobile telephone and new clothes, Sue dotes on her.
When I arrived back from the COMFORT mission, I found out that Evelyn was pregnant again. She had been on "the Injection for seven years and had been told to stop for a while".
Back to the knock on the door. Evelyn, looking exceeding uncomfortable, announces she "having pains". She is 7 months pregnant by her calculations.
I ask her a few questions, yes she is 'spotting'. Yes the pains are regular etc.
her kids are at school and her husband miles away.
I put her into my truck and we crawl down to the town's Referral Hospital.
i am feeling a bit like a Grandad to be.
When we arrive we are met by pandemonium
The entire hospital staff are out on strike. Not a medic of any shade to be found in the hospital. Chaos, crying wailing, its like something out of Dante, only hotter.
Inside the 'maternity unit' the scene is like the set of a Angelina Jollie movie. The dads, grandads grandmas and mums come at me like a wave, 'Muzungu help us!"
By now I am used to African theater so I shout back and smile.
As it calms down, Evelyn is getting distressed and I am thinking what next. I hear a scream and then groans.
I walk into the delivery room[s] and there on one bed is a kid of about 15, she is naked, sweating and in agony, her mum is holding her down.
i find an English speaker, a brand new dad, nothing to do with the girl in agony, he looks 18.
He translates, the girl has been in labor since the previous evening ( the nurses walked out at 10am today)
I gird my lions and examine her, she is about 6/7cm dilated baby's moving a little and i can hear a heartbeat.
I know i cannot do anything here. I am not credentialed for Uganda, the nurses are on strike, its an MOH hospital. I could end up in a law court
So think. I find out there is a private medical clinic some 5 miles away. The nearest city, Kampala is 200 miles away.
So i load preganant child with mum and grandma into my truck. Evelyn, now really uncomfortable is in the front.
As we were trying to leave, i am suddenly surrounded by people who need help.
At first I say no I must go and point at the girl, but they and I know i am lying, i am simply overwhelmed.
The young guy who speaks English and translated for me asks me to look at his wife. I push through the crowd to her bed.
She is so young, sweating and out of it. I think she is a problem about to happen, lift her sheet to find she had had a Caesarian within the last 24hrs. He points at an empty IV attached to the window frame and pulls out from under the bed a box with 9 remaining 500ml units of Normal Saline." Fix for me please mzee!" At this point I see a bundle of rags under the bed, "whats that?" "My son Mzee! A strong new son!"
I pick up this tiny newborn from the filth and flies on the floor and put him next to mum. She smiles. I say, "ask if she has had a drink, is she thirsty?" "I am so thirsty and hungry too".
I tell the dad no more IVI ( I risk getting in deep trouble even changing an IV) "plenty by mouth" . I leave both smiling
Outside a woman and a man meet me with a baby, it is no more than 6 months, a twin they tell me. "But this one will not suckle"
I take one look at the baby, feel its little head and chest watch its eyes roll and back arch and know why. "How long has your baby had malaria?'
"Oh three days mzee." i pinch his paper dry skin he doesnt flicker, I open an unseeing eye and search for a thready heartbeat that is almost exhausted. His back has lost its arch and he is flaccid, deeply unconscious.
I get back in the car and say I cannot help, I know the baby is doomed. I have to get the two pregnant women to a private clinic quickly
We set off. A word to the wise. Africans do not travel often in closed vehicles, they throw up. God bless mum, she opened up her handbag, a fake crocodile-skin, and her daughter threw up in it.
When we arrive, the chaos is similar but less intense
Dr Pamela examines them both.
The young girl is 7cm but making heavy weather of it, she is 16 and a PG, small in pelvis and been at it 10 hours, odds on for a Caeser'.
Evelyn, acting in sympathy gets a spurt on and starts to do it for real. The nurse tells me she is 5/6cm and moving along nicely.
At that point I tell the young woman who came with us, the child mother's mother, she is about to be a Grandma, she must be 30.
I ask what next and the hospital staff say come back in the morning and pay the bill please.
I drive home slowly thinking about the dozens I had done nothing for still waiting for the nurses to come back to the hospital, knowing that it will not be tonight
Wondering if the the baby is still alive
Trying to convince myself there was nothing i could for it
(done this a few times with babies with fulminating cerebral malaria)
We have phoned Evelyn's family, given them money for their telephones
and food and water for Evelyn
Food and water for the kids' family, I don't even know their names
And now i am going to have a beer and watch CNN
And try and forget about my Super Tuesday

Monday, January 21, 2008

Reservoir Dogs

Outbreak
One morning, just before Christmas, I was startled by the banner headlines of my local newspaper, which read, ‘Uganda Hit By Epidemics!’ Closer inspection revealed that apart from the ‘usual suspects’, cholera and meningococcal meningitis which have plagued the parts of country recently, two new pestilences are stalking the land, Bubonic Plague in Nebbi, West Nile and Ebola in Bundibugyo, western Uganda.

The outbreak of Bubonic Plague is the latest in a series of epidemics of yersinia pestis that periodically afflicts the border between northwestern Uganda and eastern Democratic Republic of Congo (DRC). The catalyst is exceptionally heavy rains; this past year has seen widespread flooding of the region. The rats, the primary reservoir, meal-ticket and main means of transport for the fleas, the key vector, move into human habitation to avoid drowning. The disease kills the rats, the fleas jump hosts and off we go; ‘The Black Death’ on a miniature scale. As usual, the local health service’s reactions were slow, medicines in short supply and a few hundred caught the disease; about 20, mainly women, have died to date.

The outbreak has been contained in the major towns along the Border but has certainly not been extinguished. It is hardly surprising; the populations are huge, over-crowded and grindingly poor. Healthcare resources are minimal and it’s a long way from Kampala. Central government’s attitude to the epidemic is exemplified by the statements made to the press by the Minister of State for Primary Healthcare, Dr Otaala and the Director General of Health Services, Dr Zaramba. At the press conference Dr Otaala attributed, “the recurrence of [P]lague in Nebbi…….is due to the primitive culture of indigenous people, where men sleep in beds and women on the floor. The people mainly affected are women because in Nebbi women only come up on the bed for sex.” Dr Zaramba, obviously seeking to clarify his Boss’s offensively patronizing statement elaborated, “The flea that causes the Plague can only jump six inches high, if everybody was sleeping on a bed, there would be no Plague in the country.” Now why didn’t someone in CDC think of that!

Ebola
‘The Plague’ has deep historical connotations for many but it no longer frightens the way it did our forefathers. Not so Ebola Hemorrhagic Fever (EHF). Thanks to Richard Preston’s not-bad account of Ebola-Reston in a government laboratory and the hysterical film ‘Outbreak’ in 1995, Ebola has a truly frightening global reputation; to be fair, not without cause. It has an impressive mortality rate of between 50% and 80%. The last time it visited Uganda was 2000/1; it sickened about 450 people in three towns, spread across the north and west, and killed 250. This time it seems to be contained in western Uganda, in a region surrounded by national parks. To date over one hundred people have been diagnosed with EHF and about 40 have died.

What makes this outbreak as interesting as it is scary, is its relatively slow progression. The estimate is it began in September 2007 and was not officially recognized until December. This may in part be to the paucity of healthcare resources in the region but skeptics also suggest that the Government kept it quiet because they did not want to frighten away the Commonwealth Heads of Government Meeting, a huge international junket held in Kampala in late November. The disease became international news in early December.

The second issue is the relatively low mortality of this outbreak compared to others. It seems that the pathogen is a new subtype (the three known to date are Ebola Sudan, Ebola Zaire and Ebola Reston). Paradoxically, the slow progression and low mortality could be very bad for us humans. Scientific opinion holds that humans are ‘dead-end hosts’ for EHF and the speed at which the virus kills us limits its ability to propagate; slowing down the process may enable it to spread more efficiently.

Finally, the so-called index case, the first known casualty, seems to have been a hunter who killed and ate a monkey (primates of all types are common food source in the region). The Government and wildlife organizations are warning locals not to eat monkeys (or chimpanzees or gorillas) which is good for the primate population but primates are just as susceptible to the disease as humans, an outbreak in 2000 in DRC is estimated to have killed 5,000 lowland gorillas. They [primates] are not the reservoir host, which normally carries the disease asymptomatically. The monkey that was killed was probably sick, this week a number of dead monkeys were found in the nearby national park.

Bats
“At this point you are entitled to ask: Damn, what is it about bats?’ David Quammen .
This outbreak comes at a key moment in the study of Ebola and growing array of viruses such as Marburg, Hendra, Nipah and the corona-viruses of SARS, which are producing new and frighteningly lethal human diseases. Virologists collaborating on international research have strong scientific evidence the reservoirs for these and other pathogens, are bats. This should come as no surprise. They have been around a long time, are hugely adaptable and can be found almost everywhere on the planet. It seems the reservoir for Ebola might be a fruit bat. There are lots of them in the forests of western Uganda and the DRC. Moreover, as human population pressure mounts, people increasingly encroach on the natural habitat of the bat and every other wild animal.

Zoonoses
This brings me to the point of my argument. Both of ‘Uganda’s Epidemics’ are zoonotic diseases: Infectious diseases that can be transmitted from animals, wild and domestic, to humans. The really surprising issue (for me at least) is how many zoonotic diseases there are and the burden of disease for which they are responsible. A recent study by the University of Edinburgh calculates that of the 1,710 pathogens afflicting humans, 832 are zoonotic (49%). Among the so-called new and emerging diseases 75% occurred first in animals.

A cursory ‘Google’ produces a veritable avalanche of information on Zoonoses. To study zoonotic disease is to study the path of human history. A couple of examples might serve to illustrate. Yellow Fever, the scourge of the New World for much of the 18th, 19th and early 20th Centuries, that almost stopped the building of the Panama Canal, probably originated in west Africa and traveled to the Americas in the mosquito larvae living in the water barrels of slave ships.


West Nile Virus, a mosquito-borne virus, appeared in the USA in 1999 attacking and killing birds, horses and humans and is now considered enzootic/endemic to the USA. It was first identified in West Nile District Uganda, the setting of my Bubonic Plague story, in 1937. How it got from Nebbi to Nebraska in 70 years is a mystery almost certainly as related to human movement as the migration of Yellow Fever.

Sleeping Sickness or Trypanosomiasis is another disease with an odious reputation. There are two types. African Trypanosomiasis is transmitted by the tse-tse fly from wild animals to domestic cattle and dogs and humans. Data on the disease is sparse; it affects mainly the rural poor who are ill-served by modern healthcare and is an appalling way to die. New World Trypanosomiasis or Chagas Disease is transmitted the Reduviid or “kissing bug”. Chagas Disease infects about 18m people every year in Central and South America, about 50,000 die. Charles Darwin is believed to have succumbed to the disease. The principal reservoir for Chagas is the domestic dog. A recent study found that people could significantly reduce the risk of infection by excluding dogs from bedrooms.

Reservoir Dogs
It seems that ‘man’s best friend’ is a reservoir for a significant number of zoonotic diseases. ‘Fido’ is host to an array of worms, which regularly infest our children, sometimes with awful results like Ocular Larva Migrans, where worms migrate to the child’s eye, and to adults, particularly a tapeworm, which migrates to the liver and causes chronic inflammation known as Hydatid Disease. In Sudan, the domestic dog is the principal reservoir for a terrible disease known as Kala Azar or Visceral Leishmaniasis. Domestic dogs are also the principal reservoir for rabies, in Africa. About 55,000 people, mainly children, die of Rabies every year.

Adapted to Travel
Despite Ebola’s fearsome reputation, it and other exotically-named viruses are seen as diseases of primitive far away places, unlikely to be encountered in the average American ER. That may be true today, Ebola has not yet adapted to distant travel, but if history is any judge, it will soon, and the results could be ghastly. Consider the evolution of the perfectly adapted virus, HIV. It almost certainly jumped to humans from primates in the same way as Ebola and probably the same part of the world. But it kills so slowly it has managed to become a global pandemic, killing millions within 50 years. Even more worrying SARS, a corona-virus which probably spilled over from horseshoe bats and which infected many thousands and killed over 700 people on its first world tour, has disappeared from our radar but will probably return with a vengeance soon, its vector, the international traveler. Finally, there is Avian Influenza, the boogey man of the infectious diseases. One of its ancestors scythed the human race less than one hundred years ago, when the world’s population was much smaller and travel slower. I shudder to think what havoc it would reap in over-crowded poverty stricken Africa or Latin America.



One Medicine
When I began examining the issue of zoonotic disease what puzzled me the most was why, given that zoonoses contribute hugely to the burden of disease and the very clear and intimate relationship between human health, animal health and the ecosystem in which both exist; their respective sciences are so stove-piped. I am not sure they always were. Where we are now seems to be the result of the narrowing of our scientific viewpoints and the specialization of our professions, driven partly by the sheer volume of what we have to know. The history of human health is replete with accounts of men and women who took a broader view of human health than simply the absence of disease; individuals who described, promoted and practiced what has been called ‘One Medicine’ or latterly ‘One Health’.

Amongst the most famous proponents of ‘One Health’, three deserve special mention. Rudolph Virchow, a 19th Century German physician and statesman, often cited as the Founder of Modern Medicine, wrote extensively about the link between human and animal diseases and coined the term zoonosis. William Osler, a Canadian physician and former pupil of Virchow who became one of the four ‘Founding Fathers’ of Johns Hopkins School of Medicine, began his scientific life as a veterinarian and is credited with creating the term ‘One Medicine’. Ironically, whilst at Oxford in 1919, Osler fell victim to the great zoonotic disease of the era, the Influenza Pandemic. Finally, no account of the One Medicine movement would be complete without mention of Calvin Schwabe, the legendry epidemiologist from UC Davis School of Veterinary Medicine, who until his death in 2006, was the leading proponent of a unified approach to human and animal health. His monograph, ‘Veterinary Medicine and Human Health’ remains a classic.

One Health Now and the Future
So where are we now? ‘One Medicine’ is unquestionably a resurgent concept, growing in strength as the public and the scientific communities become increasingly aware of global ecological disturbance directly attributable to human population pressure. The growth of One Medicine ( I prefer One Health) is evinced by the creation of organizations like the Consortium of Conservation Medicine (see www.conservationmedicine.org) and One World, One Health (see www.oneworldonehealth.org) The most recent conference, the Fifth Annual ‘One Medicine’ Symposium, held at the University of North Carolina In December 2007, provided clear directions for future collaboration between scientists involved in the entire spectrum of human, animal and ecological health. I also strongly recommend the excellent article I quoted by David Quammen in National Geographic October 2007.

One Health and the Community
I confess to some reservations regarding how ‘One Health’ is developing, essentially as the academic pursuit of elite scientists. I believe there is an urgent need to include the ‘foot soldiers’ of human and animal healthcare in the debate and in the action, particularly in the developing world where most of the action and interaction is taking place. My experience in Africa and Latin America leads me to believe that the community healthcare workers, who form the backbone of healthcare in most developing countries, know little about zoonotic disease, the inter-relationship between human and animal health, (their domestic animals or wildlife) and even less about their environment and ecology. Yet, as the Ebola story indicates, it is the community healthcare worker who comes first in contact with infectious disease outbreaks, ancient or emerging. Invariably community healthcare providers are so ill-prepared they are amongst the first victims.

I am advocating a fundamental review of what is taught and practiced as community health and healthcare in the developing world. I believe I have illustrated the vital importance of zoonotic disease in the health of people, particularly the rural poor. Most rural peoples are agriculturalists and own domestic animals; healthy animals add to the wealth of their owners, sick animals increase their poverty. The more rural people encroach upon wildlife habitats, the greater the risk that diseases which live relatively innocuously in the wild, will spill over into domestic animals and humans, Uganda’s Ebola outbreak is a good example. I offer an idea. Train two types of community healthcare worker under the same roof; one in human health and one in veterinary health and deploy them to work in teams together in the community. Maybe that’s a concept worthy of a trial project somewhere in Latin America, soon.

Monday, January 14, 2008

Dude Where's My Landcruiser?

I wrote this back in late October 2006 and have no idea why I did not post it at the time. Still, as a synopsis of events in Uganda at that time, it covers most issues and, perhaps tragically, events are little changed today. We still have no peace accord with the LRA, we still struggle with malaria, electricity remains rationed and erratic and there is an acute fuel shortage. This time because of civil unrest in Kenya but also because the government gave away its strategic fuel reserve to its friends and forgot to ask for it back. But, thanks to a bulk buy of top-of-the-range SUVs for the Commonwealth Heads of Government Meeting last November [07] we have many more Landcruisers, Hummers, BMWs etc. The roads remain awful. The population continues to increase at an exponential rate, urged on by a Government which believes that Uganda's future development hinges upon 'growing a population large enough to create its own internal market'. As far as we are aware, we have not yet been stricken by Bird Flu, but who cares. We have Ebola Fever again.

Interesting Times
"May you live in interesting times" is popularly believed to be a Chinese curse but more likely owes its origins to a speech by Robert F. Kennedy in Cape Town, South Africa, on June 7, 1966. Nevertheless, it resonates with life in Uganda today.

The 20-year conflict in the north of the country is slowly but surely drawing to a close. An agreement called a Cessation of Hostilities has been in place for a month and the Lord's Resistance Army (LRA) has moved the bulk of its 'fighters' into agreed safe areas in southern Sudan under the aegis of the army of south Sudan, the Sudanese People's Liberation Army (SPLA). The next step will be for the LRA to agree to the release of 'non-combatants'-women and children. This will probably happen within a few days.

The political center of gravity of the final stages of the conflict has now shifted to the Hague in the Netherlands and has become far more complex. At issue are matters of international law and the outcome of the debate will have global ramifications. A synopsis of events is essential to understanding the current crisis. In 1999, in order to inject fresh political initiative into ending the war in the north, the government passed into Ugandan law, an Amnesty Act, in effect offering amnesty to all LRA insurgents who surrendered. From 2000 to early 2004 many LRA members sought and received amnesty. The senior leadership did not. In 2004 the newly formed International Criminal Court (ICC) in the Hague intervened publicly in the conflict, announcing that the Ugandan government intended to amend the national Amnesty law to exclude the senior leadership of the LRA and had [also] asked the Chief Prosecutor [of] ICC to investigate charges of 'crimes against humanity.' The amnesty law was amended and in late 2005 the ICC issued arrest warrants for Joseph Kony and the top leadership of the LRA on charges of war crimes.

From the outset, there was heated debate over the perceived 'outside interference' of the ICC (even though their involvement was at the request of the Ugandan government). Many northern Ugandans believed it threatened the short-term quest for an end to the war and prospects for long-term peace, which would have to be based upon reconciliation rather than retributive justice. Many, too, saw the ICC as the 'international community' meddling in sovereign issues.

Now matters have come to a head. When peace talks began, the Ugandan government stated publicly their wish for greater flexibility over the ICC arrest warrants, even suggesting they be dropped if there was a conclusive peace deal. The LRA have repeatedly stated they will not accept any deal that includes arrest and trial by the ICC. The ICC remains implacable, insisting that the warrants be enforced and those indicted brought to trial. The result is a complicated impasse with serious implications for the future of international law. In my opinion, fault lies with the ICC, which failed to appreciate the complexities of the Uganda conflict and acted precipitously. It will be fascinating to see who backs down and how.

The Pale Horseman
Even as the peace talks in Juba began to show promising results, a scary shadow was cast over them. Pestilence appeared in the town, in the form of confirmed H5N1 'Bird Flu.' An unknown number of local domestic poultry were found dead and dying of the disease and an unknown number have since been slaughtered. There have been no confirmed cases of the disease in humans. Given my last missive to this magazine, which dealt with H5N1 in northern Uganda, I feel like Jeremiah.

Juba, the capital-city-in-the-making of south Sudan, is about 200 miles from Gulu. The road between the two towns is a constant stream of vehicles carrying every animal, vegetable and mineral that can be bought in Uganda and sold to satisfy Juba's rapidly growing appetite. The outbreak was first reported there on Sept. 6. Since that date, information has been scarce and direction from Uganda's Avian Influenza Task Force has been of the 'don't panic' variety. No attempt has been made to stop the flow of domestic poultry in and out of the towns or to map the 'backyard chicken projects' spread across the north, so that when the disease arrives, swift intervention will be possible. There are so few resources available and so little planning and preparation has been undertaken, I suspect that when the disease breaks out in the IDP [internationally displaced person] camps, the government will have little alternative but to send in the Army to supervise the culling of birds. Given that domestic fowl are a vital cash crop in the camps, this move will further alienate the Army from the IDPs. We wait with bated breath and try not to cross the line between alert and alarm.

Re-Thinking Silent Spring
On Sept. 15, the World Health Organization (WHO) made an announcement forcefully endorsing the wider use of the insecticide DDT to combat malaria across Africa. In one sweep, the WHO reversed a 30-year old policy of ambiguity on the issue of DDT and poured gasoline on a fire that has burned in Uganda for years; the argument between health professionals fighting an uphill battle against the disease, agricultural businesses that worry about the threat to their markets, particularly in Europe, and ecological activist groups, mainly international.

The data on malaria in Uganda are mind-numbing. It is the single biggest killer of children under five, accounting for about 100,000 child deaths country-wide annually. The country's maternal mortality rate is about 550 for every 100,000 pregnancies, [and] malaria is a key factor in the majority of these deaths. But the figures mean nothing unless viewed in the context of day-to-day life in the country. Whereas a kid's sick note to school in the U.S. may read, "Johnny has had a cold," in Uganda it will more likely read, "Samuel has had malaria." It is the single biggest cause of [lost work] days; nobody bats an eyelid when Fred comes back to work, looking gray and thin after a week off. They assume malaria. It is quite simply a part of life here and always has been.

In the 1980s, HIV/AIDS hijacked the public health agenda in Uganda. Interest in malaria as a disease threat waned. In the past few years, as HIV/AIDS rates dropped and public fear diminished, malaria came back on the agenda. The problem was how best to tackle disease prevention. The optimum method, proven successful in the [United States] and southern Europe in the 20th century, was by attrition of the vector, the mosquito. There is too much water in Uganda to contemplate 'draining the swamp.' Most insecticides are ineffective or too expensive for large-scale use. The most effective and cheapest, DDT, was essentially banned by international opprobrium. Many donors wouldn't fund malaria programs that contemplated using DDT. Fresh flower and vegetable markets, particularly in Europe, threatened embargoes on products originating from regions using DDT. The only tool left in the box was insecticide-treated nets (ITNs).

They (ITNs) have not proved to be the 'silver bullet.' The science has yet to be done to prove why they have not had a significant impact. I can offer a [firsthand] observation. They work for me at home [in Gulu] because we live in a spacious house with a big, well-ventilated bedroom. It is relatively cool at night, even under a mosquito net. I have spent nights in small dark windowless huts and boiled under my net. I can imagine, but only just, what it would be like to try and keep the average Ugandan family of two adults and seven kids, living in a 12-foot diameter hut, under mosquito nets all night. The number of nets distributed is no indicator of use.

So the debate has turned again to insecticides and to DDT. This is neither the time nor the place to debate the detailed science of DDT but it seems clear that the infamous reputation it gained in the '70s owes much to the amounts and methods of use. The WHO, in reversing its policy, is advocating small concentrations of DDT be sprayed in emulsions onto the walls of huts, houses and other buildings, and only [up] to a few feet above the ground. [DDT is used in a form called 'internal residual spray,' indoors only and low down toward the ground. Mosquitoes usually rest about one to three feet above the ground.]

This form of precision use, in conjunction with ITNs, is another saga in the long war against malaria and seems eminently sensible. It is already used in 10 countries in Africa. But the battle has multiple fronts and the most intractable is the political. I can understand the reticence of the Ugandan Ministers of Agriculture and Export. They worry about the fickle markets of Europe and the potential impact on a shaky economy. The decision should be a national one, made by the government, weighing the economical, health and social risks. What I cannot accept is interference from international activist groups such as Beyond Pesticides, which campaigns against the use of DDT in Africa from the comfort of its mosquito-free moral high ground on E Street in [Washington], D.C. Particularly when they rationalize their position with platitudes of the caliber of, "[W]e should be advocating for a just world where we no longer treat poverty and development with poisonous band-aids, but join together to address the root causes of insect-borne disease..." I have a piece of advice for them. If you want a credible voice in the fray, come and live in Gulu for a year. And leave behind your unaffordable Malarone [an antimalarial drug that costs $33 a week] and designer packs of insect-repellent 'wipes.'

Demography And Destiny
This month has also seen the publication of the government's State of Uganda Population Report (SUPRE). It was a damp squib, meriting only brief mention in the middle pages of the national newspapers and not a whisper of national debate. The report's most hard-hitting line is to warn of the "[m]is-match between a population growth of 3.2 per cent and economic development." Closer examination shows what a 3.2 per cent growth means: the current population of 28 million will double to 56 million in less than 20 years and double again to over 100 million by 2050. The most staggering statistic: there will be 28 million 'job seekers' in 20 years time. This is set against an economy-already struggling to keep up with a rapidly growing population with ever-rising expectations-pole-axed by a catastrophic hydro-electric power-shortage, resulting from the drop in the levels of Lake Victoria. Plans to rebuild the power industry to get back to the levels of two years ago are estimated to mature in five years, [and] to get ahead of the game will take another five years [after that]. The best advice the authors of the report can offer is "[P]lan, plan, plan."

The level of debate in the media has bordered on the fatuous. It has included celebrating 'Uganda's natural fertility as gifted by Nature,' to blaming current economic woes on colonization, [and] to dire examples of economic crises in European countries with low population growth. If 'demography is destiny' was ever true, then it is so in Uganda. And the people are ignoring it.

Dude, Where's My Land Cruiser?
You would imagine with all these momentous events in train or just over the horizon, Uganda's leaders would be consumed with affairs of state, Parliament would be conducting all-night sessions on the future of northern Uganda, bird flu, DDT and plans for economic recovery. Not so. The most contentious current issue among Uganda's lawmakers is official cars for Members of Parliament (MP). This august body of individuals, totaling 300, is debating the necessity of each having an official car to travel to their constituencies. Moreover, given the appalling state of the roads and the huge numbers of road accidents, the MPs believe it vital that their cars be SUVs (Land Cruiser size) to give them better protection in an accident. Never mind the poor constituent who has to travel the same roads crammed on the back of open pick-ups. The cost of this essential 'perk' to the taxpayer? Uganda 20 billion shillings, about $10 million, and that does not take into account fuel and maintenance. [There are about 2 million shillings to $1,000 U.S.]

But this pales into insignificance when compared to the government's spending on official vehicles. A recent government report showed that it maintains a fleet of 11,000 'luxury cars,' mostly SUVs and double-body pick-ups. The total annual cost of fuel and maintenance is 54 billion shillings, about $27 million. There is no mention of capital costs, but at $40,000 per vehicle, I estimate the total at nearly half a billion dollars.

The Ministry of Health has almost 3,000, the Ministries of Education and Agriculture over 1,000 each. The most damning indictment is that few of these vehicles ever leave Kampala or the big towns, [and] most drivers reported they had never used four-wheel drive. They are used to ferry officials from home to office and meetings. The [State of Uganda Population] Report notes that the excessive number of SUVs in the Health and Education ministries was probably the result of the large number of donor projects they are required to run. That statement is worthy of further detailed examination and I intend to do just that. The other question that nags me is how much money comes from the Ugandan taxpayer to fund this obscene display of bureaucratic excess and how much comes from taxpayers in other nations?